Staff failed to follow a resident’s care-planned transfer needs. The resident had severely impaired cognition, a moderate fall risk score, and required dependent assistance with transfers, including a Hoyer lift with 2 staff or a sit-to-stand lift. Two CNAs lifted her by the underarms and pivoted her instead of using the ordered transfer method, and one CNA stated she did not use a gait belt because the resident was too tiny. The DON acknowledged the transfers were improper and unsafe because staff did not follow the care plan or Kardex.
The facility failed to maintain safe bed systems and prevent accidents, resulting in loose side rails, unsecured or poorly fitted mattresses, and unassessed entrapment zones for multiple residents, including one who was legally blind and had a prior brain bleed after falling from bed. Maintenance logs showed incomplete or inaccurate entrapment audits, with several entrapment zones marked not applicable and some residents with rails omitted from audits, while the DON acknowledged missing side rail assessments, consents, and orders. Additional incidents included a resident with post‑stroke weakness who fell from a bed left at waist height, a resident care planned for two‑person mechanical lift transfers who was transferred by a single CNA using an incorrect sling setup, a cognitively impaired resident at risk for elopement who exited through a door with its alarm deactivated and remained outside briefly in cold weather, and a resident on anticoagulants who fell and hit her head after 11 falls in 30 days without effective revision of fall‑prevention interventions.
A resident with mild cognitive impairment and a known elopement risk, who had refused a wander guard and was to be checked every three hours, was last documented as seen at midday and later left the building by independently using the front door keypad code, remaining unsupervised outside until returning the next day. The front door keypad code had been unchanged for years, was posted in reverse on a laminated sign above the keypad, and was known to some residents, allowing them to open the door. At the same time, after an EMR system update, staff stopped routinely completing the required elopement risk assessment on all new admissions, and several newly admitted residents had no documented elopement screening despite facility policy requiring universal admission screening.
The deficiency centers on unsafe resident transfers and unsecured chemicals. A resident with hemiplegia and severe cognitive impairment, care planned for a one-person sit-to-stand (STS) lift transfer, was instead manually transferred by a CNA without the lift, during which the resident’s legs gave out, he was lowered to the floor, hit his head, and later was found to have a subdural hematoma. Another resident with severe cognitive impairment and documented inability to meet STS criteria was nonetheless assessed and care planned for STS transfers, while staff and family intermittently pivot transferred her without a gait belt and with inconsistent use of mechanical lifts, amid reports that pocket care plans and Kardex information were not kept up to date. Additionally, surveyors repeatedly observed an open tub room with unlabeled and labeled chemical spray bottles accessible on the tub, and an unattended housekeeping cart in the dining room with toilet bowl cleaner and other disinfectants unlocked and reachable by residents, contrary to staff statements that such rooms and chemicals were to be secured.
Two residents who required two-person assistance with mechanical lifts were subjected to unsafe transfers when CNAs used improperly sized, mispositioned, or incompatible full-body slings and did not follow manufacturer instructions. In one case, a resident newly admitted with a hospital-provided sling was lowered to the floor during a lift transfer after sliding forward in the sling, resulting in reported rib pain but no fractures on X-ray. In another case, a resident’s wheelchair pad and handle became entangled in a large sling during a lift, causing the wheelchair and resident to be lifted off the floor; the sling remained incorrectly positioned at mid-back when the resident was lifted again and moved to bed. Multiple CNAs and nurses reported no recent facility-specific training or competencies on mechanical or sit-to-stand lifts, selected sling sizes by guessing based on body type or using whatever sling was in the room, and lacked clear, updated care plan or Kardex documentation specifying lift type and sling size for residents who required mechanical lifts.
Two residents experienced preventable safety incidents due to inadequate supervision and failure to follow care plans. A resident with severe cognitive impairment and documented high elopement risk exited through the front door unnoticed after following a staff member, while the receptionist’s view was obstructed by multiple visitors entering, allowing the resident to reach the parking lot before being brought back inside. In a separate event, a resident at high fall risk, whose care plan required one-person assist with a gait belt for transfers, was transferred by a CNA from a bath chair to a wheelchair without a gait belt; the resident could not continue standing and was eased to the floor, resulting in a skin tear to the eyebrow and a large bruise on the upper arm, despite stable vitals and baseline ROM and neuro status.
A resident with dementia, severe cognitive impairment, a history of wandering and elopement, and a documented elopement risk assessment score exited the building unsupervised through a bedroom window that lacked an effective safety stopper and had no functioning window alarm, despite the care plan indicating one was in place. Staff last saw the resident around midnight and discovered him missing several hours later, finding the window open with the screen pushed out and later locating the resident outside. Surveyors observed multiple unsecured sliding windows in resident rooms and common areas, including the TV lounge, restorative room, therapy room, chapel, and other rooms, many of which could be opened wide enough for a person to climb out, even near residents identified as elopement risks. Several exit doors were unlocked, unalarmed, or not routinely checked, and staff, including the DON and CNAs, were not fully aware of the resident’s exit-seeking behaviors or of required window alarm interventions, leading to a deficiency at F689 for accident hazards and inadequate supervision.
A resident with Parkinson’s disease, a history of falls, and intact cognition routinely used a whirlpool tub chair without the safety belt, despite manufacturer instructions that all users must be securely belted and facility education stating all residents are to use the strap unless refusal is care planned. The resident’s care plan noted she may or may not use the belt, but her record lacked documentation that she was assessed as not requiring it or that she was educated on the risks and potential adverse outcomes of not using it. The resident reported she was not really aware she could fall by not using the belt, while staff indicated all other residents used the safety belt unless otherwise care planned, and leadership acknowledged there was no documentation of the claimed safety education.
A resident with Alzheimer’s disease, moderate cognitive impairment, a prior elopement, and a care plan requiring a wander guard and frequent checks exited the building unsupervised after the wander guard system alarmed. Although alarms sounded at the exit door, at a panel, and alerts were intended for staff radios, on-duty staff did not promptly respond because some were not near the panel, some did not hear or carry radios, and one staff member had a radio on the wrong channel. Other staff, including a ward secretary and a travel CNA who had not been re-educated, were observed silencing door panel alarms after only reviewing cameras or without understanding the alarm’s purpose, and did not physically check doors. Documentation showed the resident’s wander guard checks were either missing or performed only once daily despite orders for three checks per day, and interviews revealed inconsistent staff understanding of elopement procedures and alarm response.
A resident who had recently fallen and been re-evaluated by PT was care-planned to be transferred with a stand aid lift, and this requirement was documented on the care sheet used by staff. Despite this, a CNA transferred the resident from a commode to a bed using only a gait belt and pivot transfer, after which the resident reported increased knee pain and received pain medication. Staff interviews confirmed that care sheets were the primary tool for communicating transfer status and that they were expected to follow them, but the facility could not provide a written policy on following care plans or using mechanical lifts, even though CNA duties required adherence to the plan of care and facility processes.
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